A National Code of Ethics for Interpreters in Health Care

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2004 National Council on Interpreting in Health Care, Inc., All Rights Reserved. The NCIHC National Code of Ethics is in thepublic domain and may be reproduced as is in its current format under the copyright law of fair use. No changes may be made to thedocument except by the National Council on Interpreting in Health Care. Persons seeking to use this document should contacttheNCIHC.

The National Council on Interpreting in Health Care

A NATIONAL CODE OF ETHICS FORINTERPRETERS IN HEALTH CARE

The National Council on Interpreting in Health Care

http://www.ncihc.org

July 2004


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A National Code of Ethics for Interpreters in Health Care July 2004 Page 2 of 25

2004 National Council on Interpreting in Health Care, Inc., All Rights Reserved. The NCIHC National Code of Ethics is in thepublic domain and may be reproduced as is in its current format under the copyright law of fair use. No changes may be made to thedocument except by the National Council on Interpreting in Health Care. Persons seeking to use this document should contactNCIHC.

AcknowledgementsThis work would not have been possible without the vital input of interpreters and others whodedicated their time and knowledge to further the health care interpreter profession. The

financial support given by the U.S. Department of Health and Human Services Office

of Minority Health, Guadalupe Pacheco, Program Officer, was essential in getting this project

started.

We would like to acknowledge Maria Paz Avery for her work as primary author of"Understanding the National Code of Ethics for Interpreters in Health Care"working paper. Wewould also like to take this opportunity to thank the members of the NCIHC Standards, Training

and Certification Committee: Karin Ruschke, M.A., Co-Chair; Shiva Bidar-Sielaff, M.A., Co-

Chair 2003-2005; Linda Haffner, Co-Chair 2001-2003, current committee member; Maria PazAvery, Ph.D.; Bruce Downing, Ph.D.; Carola Green. A special thank you to Susan Kocher for

meticulously collating the hundreds of survey responses we received and Patricia Ohmans for

her insightful recommendations on how to best analyze the data. Lastly, we are grateful to EstherDiaz for her help in the final months of this project.

NCIHC BoardWilma Alvarado Little, MA,Co-Chair of the Board

Maria Michalczyk, RN, MA,Co-Chair of the BoardElaine Quinn, RN, MBA, CST, DSA,Treasurer

Lisa Morris,MSTD,Secretary

Cynthia E. Roat, MPH,Chair of the Advisory CommitteeKarin Ruschke, MA,Co-chair of the Standards, Training and Certification Committee

Shiva Bidar Sielaff, MA, Co-chair of the Standards, Training and Certification Committee

Elizabeth Jacobs, MD,Co-chair of the Research and Policy Committee

Alice Chen, MD,Co-chair of the Research and Policy CommitteeJoy Connell, Co-chair of the Organizational Development Committee

Esther Diaz,M Ed,Co-chair of the Organizational Development Committee

Julie Burns, M Ed,Co-chair of the Membership and Outreach CommitteeSusy Martorell, MPH, Co-chair of the Membership and Outreach Committee

Disclaimer for the Code of Ethics:The National Code of Ethics for Interpreters in Health Care, produced by the National Council onInterpreting in Health Care (NCIHC), Inc., is the result of a systematic, deliberate, and reflective process.The NCIHC is confident that this Code represents the principles that working interpreters believe areimportant to ensure the ethical practice of their profession. These principles are the ones that working

interpreters throughout the US have said merit serious consideration when faced with a dilemma ordifficult choice and to which they agree to be held accountable. The NCIHC regrets any inadvertent resultwhich may arise from the application of this Code. The Code is designed as a guide for both interpretersand the health care systems in which they work, and is not meant to supplant or expand policy orregulations pertinent to the provision of competent interpreter services.


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Code of Ethics for Interpreters in Health Care

The interpreter treats as confidential, within the treating team, all informationlearned in the performance of their professional duties, while observing relevant

requirements regarding disclosure.

The interpreter strives to render the message accurately, conveying the

content and spirit of the original message, taking into consideration itscultural context.

The interpreter strives to maintain impartiality and refrains from counseling,advising or projecting personal biases or beliefs.

The interpreter maintains the boundaries of the professional role, refrainingfrom personal involvement.

The interpreter continuously strives to develop awareness of his/her own and other(including biomedical) cultures encountered in the performance of their professional

duties.

The interpreter treats all parties with respect.

When the patients health, well-being, or dignity is at risk, the interpreter may bejustified in acting as an advocate. Advocacy is understood as an action taken on behalf

of an individual that goes beyond facilitating communication, with the intention of

supporting good health outcomes. Advocacy must only be undertaken after careful and

thoughtful analysis of the situation and if other less intrusive actions have not resolved

the problem.

The interpreter strives to continually further his/her knowledge and skills.

The interpreter must at all times act in a professional and ethical manner.


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Understanding the National Code of Ethics for Interpreters

in Health Care

The role of interpreter is a tightrope balancing act: A code of ethics is a good guide for the bar carried on such a

walk on the tightrope. It offers balance, some security and especially is a comfortable way to face the unknownrisks faced on the interpreters path.Anonymous Respondent to Code of Ethics Survey

Introduction

As the profession of health care interpreting in the United States matures and evolves, theimportance of creating shared understandings of what is considered high quality and ethically

appropriate principles and practices in the field becomes imperative. To this end, the National

Council on Interpreting in Health Care identified three steps that needed to take place on anational level in order to standardize the expectations that the health care industry and patients

should have of interpreters and to raise the quality of health care interpreting. The first step was

to create and build support for a single Code of Ethics that would guide the practice ofinterpreters working in health care venues. The second step was to develop a nationally

accepted, unified set of Standards of Practice based on the Code of Ethics that would define

competent practice in the field. The third step was to create a national certification process thatwould set a standard for qualification as a professional health care interpreter. (NCIHC, 2004)

The Standards, Training and Certification (STC) Committee of the National Council on

Interpreting in Health Care (NCIHC) took on the task of bringing the first step to fruition. Thegoal of the STC Committee was to create a national code of ethics that would provide the

growing profession with a set of shared, essential guiding principles expressing what are

considered morally appropriate behaviors for its practitioners as they perform their day-to-day

duties.

To achieve this goal, the STC Committee engaged in a systematic process of reviewing existingcodes of ethics, creating a draft code, conducting national focus groups to review the draft, and

eliciting feedback through a national survey. The challenge was to design a code that built on

and solidified existing work at the same time that it expanded upon this work to ensure its

relevance to all health care interpreters, irrespective of the languages or particular venue inwhich they were working.

The STC Committee started by identifying and collecting existing codes of ethics in health care

and other related areas such as legal and sign language interpreting. This process surfaced a

number of codes that were already in use at the local level by state and national associations ofinterpreters, institutions of health care, interpreter service organizations, and court programs in

the United States and Canada. The STC Committee then focused on ten codes that were

considered most relevant to their work and compared them in order to identify the elements thatwere held in common and to analyze how each approached those issues that were most difficult

and controversial in the field. Based on its analysis, the STC Committee drafted a code that

included the elements shared across these existing codes as well as a few that were controversial


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dilemmas often faced by health care interpreters. It provides an elaboration and discussion of

each principle and the interrelationships among them, acknowledging that controversies still

exist while offering the working interpreter a way to think about these controversies.

This document is organized around three major sections. The first section offers an explanation

of ethics and ethical behavior in general as well as in the context of the profession of health careinterpreting. The second section describes the core values on which this code of ethics is

grounded. Finally, the third section presents a commentary on each of the principles that makes

up the National Code of Ethics for Interpreters in Health Care.

What is Ethics?

Human beings are ethical animals.

(Simon Blackburn, 2001)

From the earliest times of human consciousness, human beings have been concerned with

defining rules of conduct or setting expectations for what is considered appropriate or the rightbehavior with respect to oneself, others, and ones environment. As Blackburn (2001) explains,

it is not so much that we, as human beings, always end up behaving exceptionally well, butrather that we constantly compare and evaluate our own and others behavior in order to find

what the shared accepted principles of right and wrong are that govern the social group around

us. These shared governing principles of right or wrong have become formalized in a number of

ways. For example, cultures embody them in their norms and customs, religions in their moralprecepts, governments in their laws, and professions in their codes of ethics.

The term ethic derives from the Greek word ethos, meaning moral custom.An ethic, therefore, is a principle of right or good conduct (The American Heritage Dictionary

of the English Language). Consequently, ethical behavior is behavior that corresponds to theaccepted and idealized principles expressing what is considered right and wrong.

As professions mature and become established, they begin to create an ethical environment ofshared expectations and norms for acceptable and appropriate behavior in the enactment of its

duties and obligations. In the words of Blackburn (2001) an ethical environment provides

. . . the surrounding climate of ideas about how to live. It determines

what we find acceptable or unacceptable, admirable or contemptible.

It determines our conception of when things are going well and when

they are going badly. It determines our conceptions of what is due tous, and what is due from us, as we relate to others. It shapes our

emotional responses, determining what is a cause of pride or shame,

or anger or gratitude, or what can be forgiven and what cannot. Itgives us our standards our standards of behavior (p. 1).

For a profession, this ethical environment is embodied in its professional code of ethics. A codeof ethics, therefore, provides a set of principles or values that govern the conduct of members of


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a profession while they are engaged in the enactment of that profession. It provides guidelines

for making judgments about what is acceptable and desirable behavior in a given context or in a

particular relationship. (NCIHC, 2002) It creates consistency and lessens arbitrariness in ourchoices when confronted with difficult dilemmas (Gonzales, et al., 1991).

The National Code of Ethics for Interpreters in Health Care sets the ethical environment for thepractice of health care interpreters in the United States. By formalizing a set of principles for

appropriate behavior into a code, an emerging profession begins to move away from the

confusion of personal preferences and opinions about what is acceptable and what is not, tostatements of preference that are shared and that, as a result, become demands on each other.

These demands form a cohesive network of rules or norms that serve to sustain the integrity

of the profession and its purpose.

It is important to understand, however, that the principles contained in a code of ethics are

abstract conceptions. A code of ethics, no matter how thorough or concise, cannot and does not

provide definitive answers to all possible dilemmas or choices an interpreter may face. It is not a

how to recipe nor is it an answer book for the many unique and problematic situations aninterpreter may face in the real world. In fact, codes of ethics inevitably contain within them the

seeds of conflict in the same way that our personal values in certain circumstances may conflictwith each other. How often, for example, do we find ourselves weighing the importance of two

values we hold dear in specific circumstances in our lives?

Why then have a code of ethics if it cannot provide definitive answers? To answer this questionwe need to go back to the purpose of a code of ethics cited earlier, that is, to provide guidance

when making judgments about the right actions to take when faced with a difficult choice. Notice

that the purpose of a code of ethics is to assist in making judgments, that is, to assist inevaluating the choices one has in a particular situation one is facing and then making a choice

based on a consideration of the appropriateness of each action.

But who decides what the principles that provide this guidance should be? Can any one person

or group arbitrarily make up the rules about right and wrong? Or can there be universal ortranscultural rules that are generally accepted by different peoples and that can stand the test of

time?

The challenge to create transcultural ethical principles is particularly salient in the field of health

care interpreting. This is a profession that, by its very nature, is made up of individuals who

represent a wide variety of cultural systems. Many have affiliations with other professions that

may have their own code of ethics. All bring to the job their own set of personal values andbeliefs that have been crafted out of their unique life experiences and circumstances. In addition,

they are faced with patients and providers who, themselves, bring into the health care encounter

a variety of ethical systems and expectations.

How, then, can a single code of ethics encompass all these ethical systems? Does it need to? Is

it possible to arrive at a transcultural set of principles that define what is appropriate and what


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is out of line for a given group of people, engaged in the same profession, at a given point in time

and place?

It is such a set of transcultural principles that the STC Committee set out to define as it listened

to what health care interpreters and those who work with them had to say about what was

important in how they performed their work. Through its discussions and review of the focusgroup and survey information, the STC Committee sought to go beyond personal beliefs and

subjective opinions and, instead, distill those principles that were central to the role of health

care interpreter, principles that had to be taken seriously by all members of the profession if theintegrity of their core duty as health care interpreters was to be maintained, that is, their duty to

make possible the communication between two parties, the patient and the provider, who do not

speak the same language in order to achieve the goal of the encounter the health and well-being

of the patient.

This core duty places the health care interpreter in a unique position. Unlike practitioners of

many other professions in which the performance of the duties are, at least to some extent,

transparent to the recipient of the services, health care interpreters are often the only ones presentin the encounter between the patient and the provider who are fully aware of what is going on.

For the most part, the interpreter is the only one who understands what each of the parties issaying to the other. This places the health care interpreter in a tremendous position of power.

Both the patient and the provider have to be able to trust that the interpreter will not abuse this

power. They need to trust that the interpreter will transmit faithfully what it is they have to say

to each other (MMIA and EDC, 1996) without the interference of the interpreters own beliefs,values, or opinions in the converted messages. They need to trust that the commitment to

confidentiality on which the provider-patient relationship is based will be maintained.

Therefore, It is the function of a code of ethics to guide the interpreter on how to wield that

power (Edwards, 1988, p.22). By adhering to the profession' s code of ethics, patients andproviders are reassured that the health care interpreter is someone who can be trusted to keep the

interests of the patient and the goals of the health care encounter in the forefront.

The Core Values of the Code of Ethics for Health Care Interpreters

The National Code of Ethics for Health Care Interpreters is grounded on three core values:beneficence, fidelity

1and respect for the importance of culture. These core values form an

overarching set of ideals that infuse the work of the health care interpreter and embody what

interpreters care about in their relationships with the patient and the provider.

1. BeneficenceA central value of the health care interpreting profession is the health and well-being of

the patient. This is a core value that is shared with other health care professions. Itmeans that the members of these professions have as their essential obligation and duty to

1We would like to acknowledge Marjorie Clay, Ph.D., ethicist at University of Massachusetts Memorial Medical Center, who called to ourattention the core values of beneficence and fidelity in relation to the work of the health care interpreter.


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support the health and well-being of the patient and her/his family system of supports

(e.g., family and community) and to do no harm.

2. FidelityThe essence of the interpreter role is encapsulated in the value of fidelity. The American

Heritage Dictionary of the English Language describes fidelity as involving theunfailing fulfillment of ones duties and obligations and the keeping of ones word or

vows. In a related nonpersonal sense, it refers to faithfulness to an original . . . This

description accurately describes the quality of the interpreter's work and the attitude withwhich interpreters should approach their work. In adhering to the essential function of

their role, interpreters make what amounts to a vow to remain faithful to the original

message as they convert utterances from one language into another without adding to,

omitting from, or distorting the original message.

3. Respect for the importance of culture and cultural differencesCulture frames the way we interpret the world, our experiences in it, and our relationship

to ourselves and others. In the area of health, culture influences the meaning given tosymptoms, the diagnosis of those symptoms, the expectations regarding the course of the

related disease or illness, the desirability and efficacy of treatments or remedies, and theprognosis. Language and culture are closely intertwined. Linguists such as Sapir (1956)

and Whorf (1978) have pointed out how language serves as an expression of the ways

that a culture organizes reality.

Health care interpreters have a twofold task in upholding their respect for the influence of

culture and cultural differences as they perform their essential duty of converting

messages from one language into another.

First, the interpreter . . . has the task not only of knowing the words that are being usedbut of understanding the underlying, culturally based propositions that give them

meaning in the context in which they are spoken. (MMIA and EDC, 1996) Without

understanding that the cultural frame of reference of the speaker is an integral part of themeaning system of that speaker, an interpreter may focus only on the surface meaning of

words and miss the essential message that the speaker is trying to convey. Second, the

interpreter has the task of always being aware that cultural differences in perspectives andalternative views of the world can lead to critical misunderstandings and

miscommunication.

This value is one that should be shared with other health care providers. Currently, thereare more and more initiatives in health care facilities and educational programs for health

care professionals that include cultural competence as an essential skill. However, until

such time as all health care professionals are fully prepared to address cultural differencesin their practice, it falls upon the health care interpreter to be cognizant of and able to

alert both the patient and the provider to the impact of culture in the health care

encounter.


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already has? If the answer to this question is yes, then the first course of action that

interpreters should take is to encourage the patient to share this information directly with the

provider. Only if this is not possible or the patient refuses to do so should interpreters considerdisclosing the information themselves. There is a fine line, however, between respecting the

autonomy of the patient and ensuring that the provider has the necessary information to treat the

patient without harming them. Interpreters have an ethical obligation to deal with this fine lineand make a conscious choice that supports the well-being of the patient.

Given that staff interpreters are employed by the health care institution, they have moreflexibility when they feel it is necessary to disclose confidential information within their

institution. However, the amount of flexibility they have also depends on their role within the

health care institution.

Information sharing with family members

In many cultures, family members are considered an extension of the individual. In such cases,

it is often said that confidentiality within the family is a non-issue. The apparent presence of

such a cultural norm does not, however, allow the interpreter (or for that matter, any health careprovider) to unilaterally make the decision to share information with family members.

Knowledge about a particular cultural norm does not translate directly into knowledge about aparticular person or family system. Whether or not a particular individual or family system

adheres to certain norms is something that needs to be confirmed. But more importantly, the

decision to share information and with whom to share it is still always the prerogative of the

patient, and information sharing by any other party should first be discussed with the patient.

There are times, however, when the expectations regarding information sharing within the family

system are not clear. If the interpreter notices that this lack of clarity is causing communicationproblems between the provider and the patient system, then the interpreter, acting within the

parameters of their role, may raise the issue with the patient and/or provider. But again, the finaldecision regarding the sharing of information should rest with the patient and be negotiated with

the provider not with the interpreter.

In other cases, the family may request that information be withheld from the patient, thereby

circumventing the patients right to know. Some patients may, in fact, wish this to be the case,

either for personal reasons or because of cultural beliefs. Again, how, with whom, when, andwhat information is shared should be negotiated with the patient. It is not the prerogative of the

interpreter or even of the provider to make this decision alone unless it is very clear that the

patient is unable to participate in their own health care. The norms of the U.S. medical system

value and protect the autonomy of the individual it is with the individual that the right toknow rests unless the patient has explicitly or implicitly indicated otherwise.

Confidentiality and the value of beneficence

There are circumstances when an interpreter may seriously have to weigh the seriousness and

importance of the principle of confidentiality against other values and principles. Such acircumstance, as has already been mentioned, occurs when the value of beneficence the well-


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being of the patient and/or others comes into play. Situations in which there is a serious

possibility that withholding information will result in harm to the patient or to others can be an

exemption to the principle of confidentiality.

Two types of situation tend to arise for interpreters. One occurs when the interpreter has

information about a patient from a previous clinical encounter. For example, the interpreter mayknow that the patient is allergic to a particular medication but the current attending provider is

unaware of this and is about to prescribe or administer the medication. Is it a breach of

confidentiality for the interpreter to intervene in this case?

Another situation occurs when the patient says something to the interpreter with the implicit or

explicit expectation that this will not be shared with the provider who may or may not be present.

Many interpreters have shared stories of sitting in the waiting room with the patient prior toseeing the provider and having the patient share information that has serious consequences or

implications related to the health and well-being of the patient. At times, this information is

shared in passing and patients are unaware of the importance of what they have said. At other

times, patients may explicitly say to the interpreter that this information is shared inconfidence and that they do not want it conveyed to the provider. Such confidences have even

been reported as occurring while in the clinical encounter with the provider present. Examplesof the type of information that is shared ranges from statements of abuse, lack of compliance

with treatment regimens, or the presence of medical conditions or symptoms in the patient or

others around them. What is the interpreter to do in these situations?

First of all, interpreters have an ethical obligation to maintain transparency. The role of the

health care interpreter is still not widely understood by patients and providers alike. Therefore,

interpreters should be very clear, especially with patients, that their role is to interpret everythingthat is said while in the presence of the provider. If there is anything that the patient does not

want to have known, then they should not say it. Secondly, interpreters should recognize thattheir commitment to confidentially refers primarily to maintaining the privacy of the patient in

relation to those outside the treating team. This means that when the patient shares information

with an interpreter that is pertinent to his or her health care, the interpreter may have an ethicalobligation to make this known to an appropriate provider if there is danger that harm could come

to the patient or to others. In all cases, however, the first obligation of the interpreter is to

encourage patients to disclose the information themselves.

Information related to abuse, whether it is child abuse or elder abuse, as well as information

about direct threats of harm to the self or to others constitutes special cases under the principle of

confidentiality. Many states mandate the disclosure of information by designated persons suchas health care providers when the abuse of a person is at stake or when a person is threatening

harm to him- or herself or others. While there are no current national legal requirements

mandating reporting by interpreters in cases of abuse or potential harm, individual states mayhave their own legal requirements for such disclosure. It is therefore, important for interpreters

to know who the mandated reporters are in their state. Beyond that, interpreters should follow

the same guidelines for disclosure of information as discussed above.


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The principle of fidelity requires that interpreters have the ability to detach themselves from the

content of the message. This is not always easy especially when the substance is difficult,

graphic, emotionally laden, or of a nature that elicits in the interpreter feelings of discomfort andeven pain. But in no instance should interpreters decide to omit or distort messages because

these are personally offensive to them or because they are uncomfortable with the language or

content of the message. If they are unable to enact their role in accordance with this ethicalprinciple, then interpreters should make this known to the parties and withdraw from the

assignment.

The language patients use to convey why they are consulting with the provider, to describe the

events (occurrences and symptoms) that led to the consultation, to communicate wishes and

desires for the future is a key source of data that providers use to arrive at an accurate and

mutually acceptable diagnosis and course of treatment (Woloshin, et. al., 1995). Interpreters arethere to make these data accessible to the provider by transforming the data transmitted in one

language into a format that the provider can understand. Providers use the interpreters

representation of what has been said as a diagnostic tool. Given this, interpreters need to be

mindful that any piece of information may be an important data source. To omit or distort any ofthe information could, therefore, result in serious clinical consequences.

In the same way, the language the provider uses is a source of data for the patient. Throughlanguage, providers convey their understanding of the patients concerns, negotiates an

appropriate diagnosis, and offers possible remedies and treatments. Through language, the

provider also builds a relationship with the patient, a relationship that can dramatically affect the

outcomes of the encounter. The patient, therefore, should be able to access both the technicalinformation and the information about the kind of relationship the provider is attempting to

establish in order to make decisions that will impact his or her health and well-being. The

patient can have full access to these data only if the interpreter faithfully transmits all messagesfrom the provider.

In both cases, the interpreter provides the essential channel for communication and as such has

the obligation to support the communication by rendering the content and spirit of the original

message as faithfully as possible.

Faithfulness of the message within its cultural context

So far, we have laid out the importance of ensuring that the content and spirit of the original

message is faithfully rendered in the other language. Why is there an additional qualifier to this

that states taking into consideration its cultural context? How does culture affect the

faithfulness of the rendering?

Many linguists, but most notably Sapir (1956) and Whorf (1978), have pointed out the

interrelationships between language and culture. According to them, a language is in many waysan expression of culture and the way in which a culture organizes reality. Cultural experiences

infuse words with meaning. The interpreter, therefore has to understand not only the words that

are being used but also the underlying, culturally-based propositions that give them meaning inthe context in which they are spoken.


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One of the challenges interpreters often face is the appearance of untranslatable words, that is,

words that refer to experiences and concepts that have no comparable referent in the otherculture (Seleskovitch, 1978). In these instances, it is not enough for the interpreter to come up

with what appears to be an equivalent word or expression, because what is key to developing

communication or shared understanding is the conveyance of what the totality of that experienceor concept means in that culture to that individual.

Does this mean that interpreters have to know and convey every single cultural nuance containedin every single utterance? Obviously not. But, what interpreters do have to know is that culture

affects meaning and if meaning is not shared miscommunication and misunderstanding occurs.

In the interest of faithfulness to the message, therefore, interpreters have an obligation to alert the

parties to the possibility of cultural barriers to communication and to assist the parties inuncovering the hidden assumptions or unstated propositions in the message in order to arrive at a

mutual understanding of the meaning.

Faithfulness of the converted message and offensive content

A question that is often raised by interpreters with respect to accuracy and completeness iswhether the interpreter should immediately and fully convey discriminatory, prejudicial, or

derogatory remarks made by either party. Interpreters often find such remarks personally

offensive and some may be unwilling to utter them even when they are not speaking in their own

voice. This, however, is not an adequate or appropriate reason for interpreters to omit suchmessages or to clean them up and make them nice.

Interpreters need to remember that everything that is said is a potential source of data. Offensive

language use by a patient may sometimes be part of their condition. If the interpreter omits suchlanguage, the provider is losing a valuable piece of data that could lead to the appropriate

diagnosis.

There are occasions, however, when remarks are made that could inadvertently be perceived as

offensive by the other party and unwittingly affect the patient-provider relationship in a negativeway. In such cases, interpreters might consider choosing to speak in their own voice, alerting the

speaker to the possible negative effects of the remarks, remind the speaker that the interpreter is

obligated to convey everything that is said, and then allow the speaker to reframe or rephrasetheir remarks if they wish to. For the most part, however, it is important for both the patient and

the provider to get the full sense of who each other is a sense that often comes through by the

manner in which parties speak to each other

Faithfulness to the message and interpreter errors

Health care interpreters work under stressful conditions. For this reason, even the most qualifiedand competent interpreter will sometimes make an error in converting a message from one

language into another. What is the interpreters ethical obligation with respect to this?


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First of all, interpreters have the ethical obligation to monitor their own interpreting

performance. As has already been mentioned, an interpreter is in the unique position, in most

cases, of being the only person in the encounter who understands both languages. Therefore,interpreters have a heightened responsibility to keep watch over their own performance and to

catch any inadvertent errors they may make. When they do, and the error is of a substantive

nature, it is then their ethical obligation to admit their error and correct it, not only in the interestof faithfulness to the original message but especially in the interest of the well-being of the

patient.

3. The interpreter strives to maintain impartiality and refrains from counseling, advising orprojecting personal biases or beliefs.

The intent of this ethical principle is to ensure that the communication and relationship betweenthe patient and the provider remain at the center of the health care encounter.

What, then, does it mean for interpreters to act impartially? The dictionary offers the following

synonyms for impartialfair, equitable, unprejudiced, unbiased, objective. To be impartial,therefore, is to act with an absence of favor or prejudice in making a judgment, free from favor

for any or either side. Impartiality applies primarily to the content of the messages that are beingconveyed by the parties in the health care encounter. In effect, it means that interpreters do not

judge the content of the messages in order to make decisions about what should be transmitted or

not, or how it should be transmitted. It also means that interpreters do not judge any of the

parties in the encounter. It means that interpreters respect the autonomy of each party in theencounter and their right to speak for themselves in the manner they wish to. It means that

interpreters respect the right of the parties to make decisions for themselves; therefore,

interpreters should not take sides or attempt to persuade either party.

Interpreters in the health care encounter understand that they are not there as primary participantsin the interaction and, therefore, are not in a position to make decisions, to advise or counsel, or

to speak for the other participants. This means that interpreters have an obligation not to let their

personal biases and beliefs intrude into the patient-provider encounter either through directcounseling or advice to either party or by injecting their biases and beliefs as if they belonged to

one of the speakers. When they do speak for themselves, they are fully aware that their function

in the encounter is that of a communication facilitator and as such their responsibility is to theprocess of communication and the facilitation of a mutual understanding of meaning. Therefore,

it is not within the interpreters set of duties to give advice or to counsel either party with respect

to the goals of the health care encounter.

This is a principle that is misunderstood and misinterpreted by many to mean that interpreters

should be disinterested in or uncaring with regard to the patient. To the contrary, as was

discussed earlier, one of the overarching values of the health care interpreters code of ethics, avalue that is shared with other health care professionals, is the well-being and welfare of the

patient. In upholding this value, interpreters fully recognize and accept the humanity and the

human needs of the parties in the encounter. Responding with empathy to a patient who mayneed comfort and reassurance is simply the response of a caring, human being.


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4. The interpreter maintains the boundaries of the professional role, refraining frompersonal involvement.

The intent of this principle is twofold: 1) to provide transparency in the service that is being

provided, and 2) to avoid potential conflicts of interest.

Transparency

To maintain professional boundaries means that interpreters fulfill only the duties of a health

care interpreter while engaged in the performance of that role and do not assume any duties that

are outside that role. Therefore, interpreters, while in an encounter in which they have been

engaged to provide interpreting services, should not assume duties that pertain to other roleswhether they are qualified in those roles or not, unless there is an explicit understanding by all

parties that the interpreter will do so. This principle is especially important for those interpreters

who are cross-trained in other health care professions such as nursing. Individuals who are

trained in such dual roles have to be very transparent about which role they are engaging in atany particular moment. If there is a need to take on their other roles or responsibilities for the

well-being of the patient, they should be transparent by letting the relevant parties know whenthe shift occurs.

To work within the professional boundaries of the interpreter role also means that interpreters are

aware of the limitations of their duties as well as the limitations of their abilities as a health careinterpreter. Again, the element of transparency is key. There are times, for example, when an

interpreter may not have the desired qualifications for the particular setting in which they have

been called to interpret (e.g., a mental health interview) but is the only interpreter available. Inmost cases where interpreters do not have the desired qualifications, the ethical obligation is to

withdraw. Where withdrawal from the assignment is not a practical option, interpreters maycontinue but only after having made known to all parties concerned what their capabilities are

and, at the same time, committing to doing the best job they can.

Personal involvement and conflicts of interest

This principle also admonishes interpreters to refrain from becoming personally involved withthe people for whom they interpret. The status of a patient, especially when it is compounded by

the inability to speak the language of the provider or know how to negotiate the health care

system, places a person in a very vulnerable position. Interpreters should not exploit this

vulnerability to their advantage.

Personal relationships also carry different types of expectations and demands that could interfere

with the performance of the role of interpreter. Avoiding personal involvements minimizes therisk of creating conflicts of interest between competing expectations and demands.

This does not mean that interpreters cannot be friendly and caring or that interpreters areprevented from establishing rapport with both patient and provider, as can occur during a formal


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or informal pre-session. The development of rapport with patients and providers during a pre-

session is a part of the interpreters professional role and does not necessarily represent personal

involvement. Establishing rapport means that the interpreter interacts with the patient in arespectful, culturally appropriate, and courteous manner, not only within the interpreted

encounter but also on other occasions. In fact, good rapport between the interpreter and the

patient can contribute to the development of a therapeutic relationship between the patient andthe provider. If the patient feels comfortable with the interpreter, it is likely that the patient will

transfer this feeling to the provider.

The question of maintaining professional boundaries that precludes personal involvement withthe patient can sometimes pose dilemmas for interpreters who come from the same small or

closely-knit cultural-linguistic community as the patient. In such communities, it is inevitable

that the interpreter will have some level of personal involvement with the patient outside the

world of the health care system. The responsibility of interpreters in these cases is to ensure thatany such personal relationships do not interfere with the ethical performance of their duties both

within the clinical encounter as well as outside the clinical encounter. For example, interpreters

are bound by the principle of confidentiality not to discuss what they may have learned about the

patient while in the clinical encounter with members in the community or even with familymembers unless given explicit permission to do so by the patient. For interpreters who are part

of the social fabric of the community for whom they interpret, there is often a fine line betweeninformation gathered only while in the performance of their interpreter duties and information

that might have been learned outside the encounter. Dealing with this fine line is not an easy

task, but the interpreter's ethical obligation is to make appropriate decisions in order to maintain

the privacy of the patient.


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begun to implement policies, structures, and expectations for cultural competence. Given this,

some health care interpreters question why they have an obligation to be culturally competent.

The answer to this question is simple: cultural competence is a value and an ethical principle that

should be shared by all members of the medical team, including the interpreter. The reality,

however, is that in most instances, interpreters will still be the member of the team most likely tohave the knowledge and understanding of cultural factors that impinge on the process of

communication and the creation of meaning. Therefore, in keeping with the principle of fidelity

to the original message and in keeping with the goal of the clinical encounter the well-being ofthe patient the interpreter has the obligation to develop their understanding of the cultures of

relevant others in the encounter and to bring this knowledge into their practice.

6. The interpreter treats all parties with respect.The intent of this principle is to remind interpreters that they have an obligation to treat everyone

in the encounter with dignity and courtesy, respecting the rights and duties of each individual,

including their own.

An essential implication of this principle is that the interpreter respects the autonomy and

expertise that each party brings to the encounter. Patients have the right to decide what is best

for them after having received appropriate and relevant information. Providers have the duty topresent their knowledge clearly and objectively so that the patient is able to make informed

choices. Interpreters have the duty to convey all messages faithfully and completely. By

respecting the rights and duties of each party in the encounter and treating all parties equally andwith dignity, interpreters can help build mutual respect within the interpreted encounter.

7. When the patients health, well-being, or dignity is at risk, the interpreter may be justifiedin acting as an advocate. Advocacy is understood as an action taken on behalf of an

individual that goes beyond facilitating communication, with the intention of supportinggood health outcomes. Advocacy must be undertaken only after careful and thoughtful

analysis of the situation and if other less intrusive actions have not resolved the problem.

Interpreters cannot help but be a witness2to what they have seen or experienced in the health

care encountergood or bad, right or wrong. Unfortunately, in the course of their practice,

interpreters will sometimes see injustices or ethically inappropriate behavior that may jeopardize

one or more persons in the encounter or that may negatively impact different groups within thehealth care institution. In such cases, interpreters may find it ethically necessary to take an

advocacy role, that is, to speak out in their own voice in order to plead a cause or attempt to

right a wrong.

The idea of advocacy in relation to health care interpreting has been and continues to be a

controversial one. In the first draft of the code, the STC Committee had not included a principle

2My thanks to Margarita Battle, former director of interpreter services at Massachusetts General Hospital for the introduction of the concept ofwitness early on in the emergence of this profession to bring attention to the fact that interpreters often see and experience things that cannot

and should not be ignored.


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that addressed advocacy. Feedback from the focus groups, however, clearly indicated that

working interpreters were asking for guidance on advocacy. Many felt that they were beingasked to take on this role inappropriately while others felt constricted from doing certain things

because it would be considered advocacy.

A large part of the controversy, however, comes from the confusion that exists about themeaning of advocacy and what its implications are in practice. On the surface, advocacy appears

to be a contradiction of the ethical principle of impartiality the obligation not to judge, take

sides, or express personal opinions and biases with respect to the content of the communicationin the clinical encounter. But these proscribed actions are clearly not examples of advocacy.

The act of advocacy should derive from clear and/or consistent observations that something is

not right and that action needs to be taken to right the wrong. On a deep level, advocacy goes tothe heart of ethical behavior for all those involved in health care to uphold the health and well-

being (social, emotional and physical) of patients and ensure that no harm is done.

Interpreters are seen in different ways by the parties. On the one hand, they are often said to be a

potentially intrusive presence, inhibiting the close, private relationship between patient andprovider. On the other hand, their presence is forgotten or considered inconsequential. In this

latter situation, a party may say or do things that go beyond the bounds of respectfulinterpersonal interactions or ethical practice. When what the interpreter sees or experiences has

a significant likelihood of serious negative consequences for a patient or patients, or, for that

matter, for others in the system, and every effort to resolve the matter judiciously with the parties

involved has been unsuccessfully tried, interpreters have the ethical obligation like any otherprofessional in the same situation to take action and advocate on behalf of the wronged

individual or individuals. Essentially, they have an obligation to bear witness, that is, to bring

forth evidence of the wrongdoing to the appropriate parties in order to redress the wrong that hasbeen done.

Assuming an advocacy stance, however, should never be taken lightly. Interpreters should

undertake this action only after careful and thoughtful analysis of the situation. In coming to this

decision to advocate or not they may want to seek the advice of supervisors and colleagues inthe field, remembering, however, to preserve the anonymity of the parties involved when seeking

such advice. In some cases, they may want to consult an ethicist. In every case, they need to

find out what the appropriate mechanisms and protocols are for such action in the institution inwhich they are interpreting and follow them. In every case, interpreters should conduct

themselves in ways that respect the privacy and rights of the parties involved.

8. The interpreter strives to continually further his/her knowledge and skills.

The intent of this principle is to ensure that interpreters continue to develop their understanding

of the content and context in which they interpret and continue to sharpen their skills.

The ability to interpret accurately and completely is, to a large extent, dependent on how muchbackground knowledge the interpreter has of the content and the context of the communication

(Seleskovitch, 1978). In the field of health care interpreting, the areas of knowledge that are


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most salient include the medical context (e.g., the basic parts and functioning of the body and

common disease syndromes and their respective treatments) and the socio-cultural context of the

patient populations for whom the interpreter interprets (e.g., beliefs about wellness and illness,folk illnesses and remedies, and the impact of assimilation and acculturation on the presentation

of illnesses). This does not mean that interpreters are expected to have the depth and breadth of

knowledge that health care professionals or anthropologist have in their respective fields.However, the more background knowledge the interpreter has, the more likely it is that the

meaning of the messages will be fully understood and therefore, the more likely it is that the

conversion will be faithful to the original message.

Interpreters are also responsible for continuing to improve and enhance language skills and their

skills of interpretation. With respect to language skills, interpreters should strive to continually

improve their proficiency in both languages, including the use of appropriate syntax, fluidity ofexpression, level of comprehensibility, and clarity of pronunciation. Because languages are

constantly changing, part of interpreter's responsibility is to keep up with new developments and

with varieties of each language with which they may be less familiar. With respect to the skills

of interpretation, interpreters should work to strengthen their ability to convert messages in eitherdirection accurately but also quickly and fluidly. Other skills of interpretation include improving

their ability to hold longer and denser chunks of meaning before having to interpret or usingmnemonic devices to assist their memory.

Professions are dynamic systems and adapt to changes in their environment. New knowledge is

created, different methodologies discovered, and new technologies created.The ethical obligation to further their knowledge and skills resides in the individual interpreter,

not in their employers. There are many opportunities available to interpreters to continue their

professional development belonging to a professional organization, reading the currentliterature, making good use of on-the-job training and supervision, and participating in

workshops and conferences to name a few.

9. The interpreter must at all times act in a professional and ethical manner.

The intent of this principle is to ensure that interpreters always strive to act in a manner that

maintains the integrity of their work and upholds the values and ethical principles of their

profession. This means that they perform their duties competently; monitor their ownperformance and behavior, including knowing when to withdraw and when to admit and correct

an error; conduct themselves with dignity; respect other professionals at the same time that they

expect respect for their profession; and do not discriminate against anyone in the provision of

their services whether based on personal characteristics such as race, class, sexual orientation, orability to reward them for their services.

To behave ethically means that interpreters do not use the knowledge they gain about individualswhile in the enactment of their duties for their personal advantage. They do not withhold their

services in order to receive favors from the parties. They do not exploit the vulnerability of the

patient who depends on them in order to be able to receive the services they need for their well-being.


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Professionalism and gifts from patients3

What does this principle mean with respect to gifts from patients? Patients often bring gifts as an

expression of appreciation and gratitude for the services they have received. Such behavior is

also often a reflection of cultural traditions. Is accepting such gifts an ethical violation?

There are two rules of thumb that interpreters can use to decide whether accepting gifts would

constitute an ethical violation on their part. First of all, interpreters should know and adhere tothe policy of the health care institution in which they are interpreting with respect to the

acceptance of gifts. Many institutional policies acknowledge the human desire to show

appreciation, a desire that is often also embodied in cultural values and traditions. Such policies

recognize that a refusal to accept a gift may be construed as an insult that could destroy trust inthe relationship. Therefore, they offer guidelines as to what types of gifts are acceptable and

which are not. Second, and most importantly, the interpreter should try to determine whether the

act of gift giving is an attempt to influence the interpreter and secure preferential or special

treatment. A possible indicator of the motivation behind the gift giving is the value of the gift.If the value is beyond what would normally be considered a token of appreciation, it should

raise questions as to the appropriateness of accepting the gift.

Whether the interpreter chooses to accept a personal gift, or to graciously decline the gift, or to

accept it only on behalf of the interpreting office, interpreters have the obligation to make clear

to the patient that their duty is to provide competent service in a fair manner to all patientswithout added reward or compensation.

Concluding Remarks

As mentioned at the beginning of this document, a code of ethics is a guiding document, not ahow-to recipe. In the commentaries, you have seen that many of the principles are interrelated.

You have also seen that there are times when the principles may conflict with each other in a

specific situation. Conflict in ethical behavior is inevitable. What a code of ethics simply doesis offer those principles that a practitioner of the profession needs to seriously consider and

weigh as they make choices about their behavior.

Ethical principles are abstract, idealized concepts of what is appropriate. But these abstract

principles cannot answer the questions that arise out of the intersections of different people and

unique circumstances. Professionals have to evaluate the consequences of each course of action

they might take and ultimately make a choice. A code of ethics provides the professional withthose ideals and values they need to consider in making those choices so that the purpose of their

profession is furthered and its integrity maintained.

It is the hope of the NCIHC and the STC Committee that the National Code of Ethics for

Interpreters in Health Care will contribute to raising the quality of practice in the profession by

3This section was patterned after the American Medical Associations Code of Ethics, principle E-10.017 Gifts from Patients.


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providing clarity and consistency at the national level. At the same time, the NCIHC and the

STC Committee recognize that the National Code of Ethics is a living document that will

continue to evolve as the field develops and matures.


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2004 National Council on Interpreting in Health Care, Inc., All Rights Reserved. The NCIHC National Code of Ethics is in thepublic domain and may be reproduced as is in its current format under the copyright law of fair use. No changes may be made to thedocument except by the National Council on Interpreting in Health Care. Persons seeking to use this document should contact

References

Blackburn, Simon. Being Good. Oxford: Oxford University Press, 2001.

California Healthcare Interpreters Association Standards & Certification Committee. California

Standards for Healthcare Interpreters: Ethical Principles, Protocols and Guidance on Roles &Intervention. 2002.

Edwards, A.B. Ethical Conduct for the Court Interpreter. The Court Manager, 3, No.2(1988): 22-25.

Gonzalez, Roseann D., Victoria F. Vasquez, and Holly Mikkelson. Fundamentals of CourtInterpreting: Theory, Policy, and Practice.Durham, N.C.: Carolina Academic Press, 1991.

Massachusetts Medical Interpreters Association and Education Development Center, Inc.Medical Interpreting Standards of Practice.Newton, MA: Education Development Center, Inc.

1996.

National Council on Interpreting in Health Care. A Code of Ethics for Health Care Interpreters:

A working paper for discussion. www.ncihc.org, 2004.

Sapir, Edward. Culture, Language, and Personality. Los Angeles: University of California

Press, 1956.

Seleskovitch, Danica. Interpreting for International Conferences. Translated by Stephanie

Dailey and E. Norman McMillan. Washington, D.C.: Pen and Booth, 1978.

Whorf, Benjamin Lee. The Retention of Habitual Thought and Behavior to Language. InLanguage, Thought, and Reality. Edited by John B. Carroll. Cambridge, Mass: M.I.T. Press,

1978.

Woloshin, Steven, Nina A. Bickell, Lisa M. Schwartz, Francesca Gany, and Gilbert Welch.

Language Barriers in Medicine in the United States. JAMA. 273, No.9, (1995): 724-728.

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